Journal of Thrombosis and Thrombolysis

, Volume 44, Issue 2, pp 234–237 | Cite as

Biventricular thrombosis in biventricular stress(takotsubo)-cardiomyopathy

  • Luisa De Gennaro
  • Massimo Ruggiero
  • Sergio Musci
  • Francesco Tota
  • Domenica De Laura
  • Manuela Resta
  • Nicola Locuratolo
  • Francesco Santoro
  • Natale Daniele BrunettiEmail author
  • Pasquale Caldarola


Endo-ventricular thrombosis represents a possible clinical complication of stress(takotsubo)-cardiomyopathy (SC). Depressed ventricular systolic ventricular function, localized left ventricular (LV) dyskinesis, but also an increased pro-thrombotic state induced by catecholamine surge may facilitate the occurrence of endovascular thrombosis in SC. SC, however, may also present as right ventricular (RV) dysfunction or even as biventricular ballooning. Ventricular thrombosis may therefore theoretically occur in either ventricles or both. We report the case of an 88-year old woman, with vascular dementia and depression, admitted for abdominal pain, diarrhea, and rectal bleeding. Unexpectedly, electrocardiogram showed induced QT-prolongation with diffuse negative T-waves, while echocardiogram severe LV dysfunction (ejection fraction 35%), but also RV dysfunction and biventricular thrombosis. The diagnosis was therefore biventricular SC complicated by biventricular thrombosis; LV recovered after 10 days. When SC presents with a biventricular involvement, a careful assessment of either ventricular cavities should be therefore recommended to exclude the presence of (bi)ventricular thrombosis. It remains unresolved whether biventricular SC may represent a condition at higher risk of ventricular thrombosis.


Stress cardiomyopathy Biventricular dyskinesis Biventricular thrombosis 


Compliance with ethical standards

Conflict of interest

Authors have no potential conflict of interest to disclose.

Informed consent

The study is purely observational; a patient’s informed consent was signed.

Supplementary material

Four-chamber view showing apical dyskinesis and left ventricular thrombosis (WMV 56 KB)

Short-axis view showing left ventricular thrombosis (WMV 47 KB)

Sub-costal view showing right ventricular thrombosis (asterisk) and left ventricular thrombosis (arrow) (WMV 50 KB)


  1. 1.
    Wong GR, Roberts-Thomson R, Parvar SL, Nelson AJ (2016) Large apical thrombus due to Takotsubo cardiomyopathy. BMJ Case Rep. doi: 10.1136/bcr-2016-214503
  2. 2.
    Lee PH, Song JK, Park IK, Sun BJ, Lee SG, Yim JH, Choi HO (2011) Takotsubo cardiomyopathy: a case of persistent apical ballooning complicated by an apical mural thrombus. Korean J Intern Med 26(4):455–459CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Azzarelli S, Galassi AR, Amico F, Giacoppo M, Argentino V, Giordano G, Fiscella A (2008) Apical thrombus in a patient with takotsubo cardiomyopathy. J Cardiovasc Med 9(8):831–833CrossRefGoogle Scholar
  4. 4.
    Tobar R, Rotzak R, Rozenman Y (2009) Apical thrombus associated with Takotsubo cardiomyopathy in a young woman. Echocardiography 26(5):575–580CrossRefPubMedGoogle Scholar
  5. 5.
    Kim SM, Aikat S, Bailey A, White M (2012) Takotsubo cardiomyopathy as a source of cardioembolic cerebral infarction. BMJ Case Rep. doi: 10.1136/bcr-2012-006835
  6. 6.
    Jabara R, Gadesam R, Pendyala L, Chronos N, King SB, Chen JP (2009) Comparison of the clinical characteristics of apical and non-apical variants of “broken heart” (takotsubo) syndrome in the United States. J Invasive Cardiol 21(5):216–222PubMedGoogle Scholar
  7. 7.
    Brunetti ND, Ieva R, Correale M, De Gennaro L, Pellegrino PL, Dioguardi E, Di Biase M (2009) Alternative presentation of tako-tsubo syndrome with spontaneous echo-contrast and “onion” shaped apical ballooning. J Thromb Thrombolysis 28(2):242–244CrossRefPubMedGoogle Scholar
  8. 8.
    Casavecchia G, Gravina M, Totaro A, Ieva R, Vinci R, Macarini L, Di Biase M, Brunetti ND (2015) “Right” ventricular assessment by cardiac magnetic resonance in Takotsubo cardiomyopathy. Am J Emerg Med 33(3):469CrossRefPubMedGoogle Scholar
  9. 9.
    Santoro F, Ieva R, Di Martino LF, Musaico F, Scarcia M, Ferraretti A, Di Biase M, Brunetti ND (2014) Incomplete leaflet coaptation and tricuspid regurgitation mechanism in right ventricular Tako-Tsubo cardiomyopathy. Int J Cardiol 177(3):e99–101CrossRefPubMedGoogle Scholar
  10. 10.
    Novak G, Kross K, Follmer K, Brofferio A, Shirani J (2007) Transient biventricular apical ballooning: a unique presentation of the “broken heart”. Clin Cardiol 30(7):355–358CrossRefPubMedGoogle Scholar
  11. 11.
    Kagiyama N, Okura H, Tamada T, Imai K, Yamada R, Kume T, Hayashida A, Neishi Y, Kawamoto T, Yoshida K (2016) Impact of right ventricular involvement on the prognosis of Takotsubo cardiomyopathy. Eur Heart J Cardiovasc Imaging 17(2):210–216CrossRefPubMedGoogle Scholar
  12. 12.
    Becher T, El-Battrawy I, Baumann S, Fastner C, Behnes M, Loßnitzer D, Elmas E, Hoffmann U, Papavassiliu T, Kuschyk J, Dösch C, Röger S, Hillenbrand D, Schramm K, Borggrefe M, Akin I (2016) Characteristics and long-term outcome of right ventricular involvement in Takotsubo cardiomyopathy. Int J Cardiol 220:371–375CrossRefPubMedGoogle Scholar
  13. 13.
    Kurisu S, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Nakama Y, Maruhashi T, Kagawa E, Dai K (2011) Incidence and treatment of left ventricular apical thrombosis in Tako-tsubo cardiomyopathy. Int J Cardiol 146(3):e58–e60CrossRefPubMedGoogle Scholar
  14. 14.
    Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, Cammann VL, Sarcon A, Geyer V, Neumann CA, Seifert B, Hellermann J, Schwyzer M, Eisenhardt K, Jenewein J, Franke J, Katus HA, Burgdorf C, Schunkert H, Moeller C, Thiele H, Bauersachs J, Tschöpe C, Schultheiss HP, Laney CA, Rajan L, Michels G, Pfister R, Ukena C, Böhm M, Erbel R, Cuneo A, Kuck KH, Jacobshagen C, Hasenfuss G, Karakas M, Koenig W, Rottbauer W, Said SM, Braun-Dullaeus RC, Cuculi F, Banning A, Fischer TA, Vasankari T, Airaksinen KE, Fijalkowski M, Rynkiewicz A, Pawlak M, Opolski G, Dworakowski R, MacCarthy P, Kaiser C, Osswald S, Galiuto L, Crea F, Dichtl W, Franz WM, Empen K, Felix SB, Delmas C, Lairez O, Erne P, Bax JJ, Ford I, Ruschitzka F, Prasad A, Lüscher TF (2015) Clinical features and outcomes of Takotsubo (stress) cardiomyopathy. N Engl J Med 373(10):929–938CrossRefPubMedGoogle Scholar
  15. 15.
    Mitsuma W, Kodama M, Ito M, Kimura S, Tanaka K, Hoyano M, Hirono S, Aizawa Y (2010) Thromboembolism in Takotsubo cardiomyopathy. Int J Cardiol 139(1):98–100CrossRefPubMedGoogle Scholar
  16. 16.
    Delewi R, Zijlstra F, Piek JJ (2012) Left ventricular thrombus formation after acute myocardial infarction. Heart 98(23):1743–1749CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    de Gregorio C, Grimaldi P, Lentini C (2008) Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: a systematic review. Int J Cardiol 131(1):18–24CrossRefPubMedGoogle Scholar
  18. 18.
    Yoshida S, Miwa K, Matsubara T, Yasuda T, Inoue M, Teramoto R, Okada H, Kanaya H, Hayashi K, Konno T, Kawashiri MA, Yamagishi M (2012) Stress-induced takotsubo cardiomyopathy complicated with wall rupture and thrombus formation. Int J Cardiol 161(1):e18–20.CrossRefPubMedGoogle Scholar
  19. 19.
    Korosoglou G, Haars A, Kuecherer H, Giannitsis E, Katus HA (2007) Prompt resolution of an apical left ventricular thrombus in a patient with takotsubo cardiomyopathy. Int J Cardiol 116(3):e88–91CrossRefPubMedGoogle Scholar
  20. 20.
    Matsuzono K, Ikeda Y, Deguchi S, Yamashita T, Kurata T, Deguchi K, Abe K (2013) Cerebral embolic stroke after disappearing takotsubo cardiomyopathy. J Stroke Cerebrovasc Dis 22(8):e682–e683CrossRefPubMedGoogle Scholar
  21. 21.
    Brunetti ND, Santoro F, De Gennaro L, Correale M, Kentaro H, Gaglione A, Di Biase M (2016) Therapy of stress (takotsubo) cardiomyopathy: present shortcomings and future perspectives. Future Cardiol 12(5):563–572CrossRefPubMedGoogle Scholar
  22. 22.
    Cecchi E, Parodi G, Fatucchi S, Angelotti P, Giglioli C, Gori AM, Bandinelli B, Bellandi B, Sticchi E, Romagnuolo I, Mannini L, Antoniucci D, Abbate R (2016) Prevalence of thrombophilic disorders in takotsubo patients: the (ThROmbophylia in TAkotsubo cardiomyopathy) TROTA study. Clin Res Cardiol 105(9):717–726CrossRefPubMedGoogle Scholar
  23. 23.
    Santoro F, Tarantino N, Ieva R, Musaico F, Di Biase M, Brunetti ND (2014) Hereditary hypercoagulable state and Takotsubo cardiomyopathy: a possible link. Int J Cardiol 174(3):e108–e109CrossRefPubMedGoogle Scholar
  24. 24.
    Santoro F, Ieva R, Ferraretti A, Carapelle E, De Gennaro L, Specchio LM, Di Biase M, Brunetti ND (2017) Early recurrence of Tako-Tsubo cardiomyopathy in an elderly woman with amyotrophic lateral sclerosis: different triggers inducing different apical ballooning patterns. J Cardiovasc Med. doi: 10.2459/JCM.0b013e328364dcbc Google Scholar
  25. 25.
    Ieva R, Santoro F, Ferraretti A, Spennati G, De Gennaro L, Di Biase M, Brunetti ND (2013) Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: in the beginning was basal hyperkinesis? Int J Cardiol 167(3):e55–e57CrossRefPubMedGoogle Scholar
  26. 26.
    De Gennaro L, De Tommasi E, Ramunni G, Boscia F, Di Biase M, Brunetti ND (2012) Tako-Tsubo syndrome in a psychiatric woman with bipolar disorder. Int J Cardiol 157(3):e46–e47CrossRefPubMedGoogle Scholar
  27. 27.
    Santoro F, Carapelle E, Cieza Ortiz SI, Musaico F, Ferraretti A, d’Orsi G, Specchio LM, Di Biase M, Brunetti ND (2013) Potential links between neurological disease and Tako-Tsubo cardiomyopathy: a literature review. Int J Cardiol 168(2):688–691CrossRefPubMedGoogle Scholar
  28. 28.
    Finsterer J, Stöllberger C, Pulgram T (2015) Paraneoplastic takotsubo syndrome with ventricular thrombus and stroke. Herz 40(4):632–634CrossRefPubMedGoogle Scholar
  29. 29.
    Vizzardi E, Bonadei I, Piovanelli B, Bugatti S, D’Aloia A (2014) Biventricular Tako-Tsubo cardiomyopathy: usefulness of 2D speckle tracking strain echocardiography. J Clin Ultrasound 42(2):121–124CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Luisa De Gennaro
    • 1
  • Massimo Ruggiero
    • 1
  • Sergio Musci
    • 1
  • Francesco Tota
    • 1
  • Domenica De Laura
    • 1
  • Manuela Resta
    • 1
  • Nicola Locuratolo
    • 1
  • Francesco Santoro
    • 2
    • 3
  • Natale Daniele Brunetti
    • 2
    Email author
  • Pasquale Caldarola
    • 1
  1. 1.Cardiology DepartementOspedale San PaoloBariItaly
  2. 2.Department of Medical and&Surgical SciencesUniversity of FoggiaFoggiaItaly
  3. 3.Cardiology DepartmentAsklepios Klinik Sankt GeorgHamburgGermany

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